arlier this year, the New York Times gave front-page coverage to two Boston internists who left their positions at the Beth Israel Deaconess Medical Center to pursue a new kind of private practice, called concierge medicine. The article detailed how for an annual fee$4,000 for an individual and $7,500 for a familypatients could get extra-special medical care from their doctor beyond insurance coverage. The paying patient would have 24-hour access to the doctor, same-day appointments, longer visits, and even house calls. Rather than seeing thousands of patients, the doctors could reduce their patient panel to 300, allowing them greater flexibility with each patient. The Massachusetts doctors are not alone. So-called platinum practices are also in Washington, Florida, and California.

After the article ran, the New York Times published several letters from readers criticizing the concept of concierge medicine. The newspaper also ran an editorial saying it will be a sad commentary on American medicine if a large number of physicians begin to charge extra fees as a prerequisite for quality care.

The editorial response, demonizing those doctors who seemed to be placing their financial well-being above maintaining their moral high ground, seems to me to be perpetuating a false dichotomy: the altruistic doctor vs. the acquisitive doctor, as if every physician must choose one or the other. When real doctors make decisions about positioning their practice, social responsibility, financial rewards, and a desire to be an effective clinician are just a few of the many things taken into consideration.

For me, a first-year medical student, I can see how the doctors pursuing concierge care might be making a justifiable decision to care for their patients. What is medicine about for an idealistic medical student? The desire to heal. Relationships of warmth and respect with patients about whom we care deeply. These come to mind immediately.

I can imagine concierge care as an attempt to bring medicine back to the ideals of a happier time before HMOs, a time that exists as a legend among young physicians-in-training. The physicians who are entering these concierge practices are trying to reclaim the time with patients that they lost in the struggle to stay profitable. Though technically on call all the time, the doctors have a lightened and less stressful schedule, with better pay. There is no longer an incentive to rush through patient after patient in assembly line fashion.

I can envision a medical practice where physicians could spend time getting to know their patients, accompany them to see specialists, and have the liberty to make house calls. In spending an hour with a patient instead of 15 minutes and showing up at the door when the kids have a fever they can regain a foothold in what the financial and legal aspects of modern medical practice have been eroding for yearspatient trust.

On the other hand, many of us enter this profession with a deep sense of social responsibility, and it seems unethical to limit ones practice to those patients who can pay additional fees. I cannot imagine that a single student in my class would say that he or she would refuse someone care or even provide preferential treatment based on the patients ability to pay. Concierge practices exclude patients based on their incomes. More sinister than that, though, is that by limiting the number of patients carried, they increase the burden on physicians who take in those patients who cannot afford the higher tier of medical care. In a country where more than 40 million people are uninsured, being a primary practitioner with a patient panel of only 100, for example, seems unconscionable.

Within the medical guild, it is appropriate to talk about financial concerns, but in the eyes of the public the medical profession still attempts to retain the image of the doctor who is respected both for mastery of the healing arts and the generosity and fairness of his or her practice of them. As physicians negotiate the rocky territory between expectations and realities, between the high ground and the middle ground, they are subject to incredible pressure. Some will fly to the extremes, practicing concierge medicine in the homes of the wealthy or living more ascetically to serve the needs of the poor. Most will fall somewhere in between.

Can physicians ever be comfortable with the balance they have to strike between providing for their patients and providing for themselves? Not if they feel so compelled to identify themselves with the social construct of the good, altruistic doctor that they fail to recognize that this polarized image is not real. Should physicians doubt their own integrity if they do not live up to an unattainable ideal? Of course not. Nor should they feel compelled to foist the responsibility for the nature of their practices on the hospital system, the insurance system, or the non-existent national health care system rather than on their own needs.

I see my peers already trying to become the ideal doctor, and I uncomfortably find myself striving as well for that same pinnacle. As a physician-in-training, I know I will eventually have to make choices about the way I practice based on both my quality of life and my sense of social responsibility. I can justify my practice decisions to myself and my colleagues, but can I do so to a public that seems to see medicine in black and white? I am coming to understand that to balance emotional and financial self-preservation with a commitment to public service is not to compromise my ideals, but to replace a caricature with an acknowledgment of reality.

Noah Matthew Raizman '05 is a first-year student at P&S. Robin Eisner, editor of In Vivo, provides editorial guidance for Point of View contributions.